HomeMy Public PortalAbout9517 LAS TUNAS DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION MISCELLANEOUS APPLICATION
. o'-�- `•'. CE 875 (11-84)
I hereby affirm tCE 875
: " hat ,I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION
insure, or a certificate of;Workers'Compensation Insurance,or
a certified copy the eof(Sec. 3800 LL b.C
Policy No7 1Company ATr COm61Zn$At/On FOR APPLICANT TO FILL IN BUILDING
Tn5(44ANCB J"{�n ADDRESS
Certified copy is hereby furnished. ILDNG —� 7 L LOCALITY
ADDRESS I
Certified co is filed with the county building inspection . NEAR EST
copy" P OCALITY
department. ceoss sT.
Date If?-i _�j_Applicant EAREST /fir) {� �Jq�/J�j/��j DISTRICT NO. G UP TYPE OC SSED BY
CRDSS ST. C t�O ve-, !, P'��/" _V !-v �J 8 UUU CONST. ,
CERTIFICATE OF EXEMPTION F OM\VORKE S' LEGAL
COMPENSATION INSURANCE DESCRIPTION Lor NO. BLOCK MAP / HIGHWAY
NO./�-'�6(CIRCLE) STATE MAJOR SECOND LOCAL
NO. OF BLDGS.
(This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS
by the permit is for one hundred dollars ($100) or less.) USE of
I certify that in the performance of the work for which.this SIZE OF LOT EXISTING BLDG. C J �
C:3
permit is issued, I shall not employ any person in any manner 1,6WNER
so as to become subject to the Workers' Compensation Laws. hhkoa hex ttR OCCUPANCY GROUP C.-I
AIL ^7 /� ? o
ADDRESS �' S� / !.� (�.S /(yr�LL5 DZl 'Z3
Date Applicant LLI
�I TEL. �8G16 JS 6 OCCUPANT LOAD
NOTICE TO APPLICANT: If, after makingthis Certificate of ry No.
Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE: .
Compensation provisions of the Labor Code,you must forth
with comply with such provisions or this permit shall be TRAILER USE GEOLOGY INSPECTION Eldeemed revoked. � E] No Spec. Knowl.
LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices
I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW)
9 (commencing with Section 7000) of Division 3 of the Busi- NO. OF EXITS
ness and Professions Code,and my license is in full force and
effect. PARKING REQ'D �. PROVIDED I I
SPACES LL�� LL_��J
License Number Lic. Class LIMITED TIME USE
Contractor Date -TE DATE
El I am exempt from the licensing requirements as I am a
INSPECTOR'S
licensed architect or a registered professional engineer SIZE OF NO. OF FROM: TO:
acting in my professional capacity (Section 7051, Bus- EXISTING BLDG. STORIES SIGNATURE
iness and Professions Code). FINAL APPROVAL
SENT USE OF BUILDING <� 6-5 T/• 6
Lic.or Reg.No. Date
HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS
ON LOT AND USE
I hereby affirm that I am exempt from the Contractor's
License Law for the following reason (Section 7031.5, Busi-
ness and Professions Code): NO, PARKING
SPACES PROVIDED
I, as owner of the property, will do the work and the
structure is not intended or offered for sale (Section
7044,Business and Professions Code).
CONSTRUCTION LENDING AGENCY PROPOSED USE OF BUILDING 9574,0 A
I hereby affirm that there is a construction lending agency , # 0 0 0 0 8 8
for the performance of the work for which this permit is il
issued(Sec. 3097,Civ.C.). \ 0 0 0 0 0 0 o z
Lender's Name
PROPOSED MAX. OCC. :1 023-86
Lender's Address
I certify that I have read this application and state that the PERMIT FEE ,
above information is correct.I agree to comply with all County ISSUANCE FEE
ordinances and State laws relating to building construction,
and hereby authorize representatives of this County to enter TOTAL FEE
upon le above-mentioned property for inspectio purposes.
i. SEE REVERSE FOR EXPLANATORY LANGUAGE
• � 9-r s� `
Sign e of Permi4ife Date